Role of Growth Hormone, Glutamine and Enteral Nutrition in Pediatric Short Bowel Syndrome: A Pilot Follow-Up Study

Abstract

Objective Aim of the study was to evaluate whether growth hormone (GH), glutamine (Gln), and enteral nutrition (EN) have a positive effect on intestinal adaptation in pediatric patients with short bowel syndrome (SBS).

Method 7 pediatric patients with SBS (small bowel remnant length: 60.57 ± 15.18 cm; mean ± SEM) were treated with GH (0.05 mg∕kg∕day), supplemental Gln (0.45 g∕kg∕day), plus EN for 3 weeks. After 3 weeks of treatment, GH was discontinued, and patients were maintained on Gln and EN or additionally received a high-carbohydrate-low-fat diet. Repeat treatment was given at regular intervals. Changes in weight and height increase, intestinal absorptive capacity and blood indices were evaluated.

Result All patients completed the treatment. The intestinal absorptive capacity and plasma levels of proteins were significantly improved after treatment. There were no major adverse effects in any patient and no death occurred. Growth velocity was also well maintained on follow-up. 6 patients were weaned off PN and lived on HCLF diet supplement with EN, while the last patient required less volume of PN.

Conclusion Multiple treatment approaches with GH, Gln, and EN at an early stage significantly improved intestinal adaptation in pediatric patients with SBS. Furthermore, the positive effect appeared to be sustained even after GH was discontinued.

Keywords

short bowel syndrome - pediatrics - growth hormone - glutamine - enteral nutrition

• References

• 1 Goulet O, Ruemmele F. Causes and management of intestinal failure in children. Gastroenterology 2006; 130: S16-S28
• 2 Sigalet DL. Short bowel syndrome in infants and children: an overview. Semin Pediatr Surg 2001; 10: 49-55
• 3 Kelly DA. Liver complications of pediatric parenteral nutrition-epidemiology. Nutrition 1998; 14: 153-157
• 4 Byrne TA, Persinger RL, Young LS , et al. A new treatment for patients with short-bowel syndrome. Growth hormone, glutamine, and a modified diet. Ann Surg 1995; 222: 243-255
• 5 Scolapio JS, Camilleri M, Fleming R , et al. Effect of growth hormone, glutamine, and diet on adaptation in short-bowel syndrome: a randomized, controlled study. Gastroenterology 1997; 113: 1074-1081
• 6 Byrne TA, Wilmore DW, Iyer K , et al. Growth hormone, glutamine, and an optimal diet reduces parenteral nutrition in patients with short bowel syndrome: A prospective, randomized, placebo-controlled, double-blind clinical trial. Annals of Surgery 2005; 242: 655-661
• 7 Zhu WM, Li N, Li JS. Effect of recombinant human growth hormone and enteral nutrition on short bowel syndrome. Journal of Parenteral and Enteral Nutrition 2004; 28: 377-381
• 8 Ladd AP, Grosfeld JL, Pescovitz OH , et al. The effect of growth hormone supplementation on late nutritional independence in pediatric patients with short bowel syndrome. J Pediatr Surg 2005; 40: 442-445
• 9 Rickham PP. Massive small intestinal resection in newborn infants. Ann R Coll Surg Engl 1967; 41: 480-492
• 10 Wales PW, de Silva N, Kim J , et al. Neonatal short bowel syndrome: population-based estimates of incidence and mortality rates. J Pediatr Surg 2004; 39: 690-695
• 11 Kjeldahl J. Neue Methode zur Bestimmung des Stickstoffs in organischen Körpern. Z Anal Chem 1883; 22: 366-369
• 12 DiBaise JK, Young RJ, Vanderhoof JA. Intestinal rehabilitation and the short bowel syndrome: Part 2. Am J Gastroenterol 2004; 99: 1823-1832
• 13 Sukhotnik I, Siplovich L, Shiloni E , et al. Intestinal adaptation in short-bowel syndrome in infants and children: a collective review. Pediatr Surg Int 2002; 18: 258-263
• 14 Krysiak R, Gdula-Dymek A, Bednarska-Czerwiñska A , et al. Growth hormone therapy in children and adults. Pharmacol Rep 2007; 59: 500-516
• 15 Inoue Y, Copeland EM, Souba WW. Growth hormone enhances amino acid uptake by the human small intestine. Ann Surg 1994; 219: 715-724
• 16 Challacombe DN, Wheeler EE. The trophic action of human growth hormone on human duodenal mucosa cultured in vitro. J Pediatr Gastroenterol Nutr 1995; 21: 50-53
• 17 Jiang XH, Zhu WM, Li N , et al. Effects of continuous enteral L-arginine in a rat model of the short bowel syndrome. Asia Pacific Journal of Clinical Nutrition 2007; 16: 554-560
• 18 van der Hulst RR, van Kreel BK, von Meyenfeldt MF , et al. Glutamine and the preservation of gut integrity. Lancet 1993; 341: 1363-1365
• 19 Rhoads JM, Argenzio RA, Chen W , et al. L-glutamine stimulates intestinal cell proliferation and activates mitogen-activated protein kinases. Am J Physiol 1997; 272: 943-953
• 20 Lobie PE, Breipohl W, Waters MJ. Growth hormone receptor expression in the rat gastrointestinal tract. Endocrinology 1990; 126: 299-306
• 21 Matarese LE, Seidner DL, Steiger E. Growth hormone, glutamine, and modified diet for intestinal adaptation. Journal of the American Dietetic Association 2004; 104: 1265-1272
• 22 Thissen JP, Ketelslegers JM, Underwood LE. Nutritional regulation of the insulin-like growth factors. Endocr Rev 1994; 15: 80-101
• 23 Wilmore DW. Impediments to the successful use of anabolic agents in clinical care. JPEN 1999; 23 (suppl) 210-213
• 24 Nucci AM, Finegold DN, Yaworski JA , et al. Results of growth trophic therapy in children with short bowel syndrome. Journal Of Pediatric Surgery 2004; 39: 335-339
• 25 Velasco B, Lassaletta L, Gracia R , et al. Intestinal lengthening and growth hormone in extreme short bowel syndrome: a case report. J Pediatr Surg 1999; 34: 1423-1424